Antibiotics have saved countless lives over the years, but their overuse has lead to problems including antibiotic-resistant bacteria. Dr. Mary R. Clance, an epidemiologist at Anne Arundel Medical Center, discusses the history, troubles and appropriate uses of the drugs.
How have antibiotics contributed to public health since their discovery and what is their status now?
The collective memory of death from infectious disease is short-lived. Death from pneumonia, puerperal fever, post-operative infection, urinary and skin infections were commonplace just two generations ago. Pneumonia was the leading cause of death at the beginning of the 20th century.
The development and success of antimicrobials resulted in a lack of respect for the microbial world and complacency among physicians and health policy makers. Now, because of the real presence of antibiotic resistance and the decline in the production of new antimicrobials to combat this threat, some have stated that we have entered the "post antibiotic era."
Antibiotic development is not lucrative compared to chronic disease drugs that are taken over long periods of time so the economic incentive for the pharmaceutical industry to development new antimicrobials is lacking.
How has misuse contributed to problems and what are the problems?
Antibiotics are not harmless chemicals; deaths occur each year in most hospitals due to adverse events triggered by antibiotics (Clostridium difficile colitis, renal failure, bone marrow suppression, drug interaction, allergic reaction). It is estimated that at least 30 percent of the antibiotics prescribed in hospitals is not necessary. In the time-pressured outpatient arena, there are many forces that fuel unnecessary antibiotic prescribing: patient demand/expectation/anxiety, clinical uncertainty, habit, lack of time, expediency, fear of litigation.
Antibiotic use has many unintended negative consequences. Antibiotics produce a Darwinian challenge to the normal commensal human flora (skin and gut). Destruction of the normal flora opens the way for invasive pathogens like Clostridium difficile. Though not perfectly understood, the normal human microbiome plays an important role in host defense against invasive pathogens.
We live during an era of the global transmission of antibiotic resistant genes harbored by plasmids. Humans can circumnavigate the globe in less than 24 hours carrying with them the newest generation of multi-drug resistant organisms. Ready access to antibiotics without prescription, the lack of rigorous infection control standards or the health infrastructure needed for surveillance in other countries contribute to the genesis of the perfect storm.
Antibiotic use in humans is only part of the problem. The systematic use of antibiotics as "growth promoters" in animal feed by agribusiness is not generally known by the public. Antibiotic use in the production of animals for human consumption is linked to antibiotic resistance in the food chain and environment. In terms of millions of pounds, far more antibiotics are consumed by animals than humans in the United States. This practice has been successfully outlawed in Europe and other countries. Efforts to curb this practice in this country have not been successful. The 2013 Food and Drug Administration guidance document calls for only nonbinding voluntary compliance.
What kinds of infections are antibiotics most appropriate for now and when don't antibiotics work?
Antibiotics are not indicated for most upper respiratory infections (coughs, colds, sore throats, conjunctivitis, sinusitis etc). A common misconception is that a purulent yellow or green nasal discharge mandates antibiotic treatment: No. Antibiotics are not needed for viral infections such as influenza or for most cases of episodic gastroenteritis. When an antibiotic is truly indicated, the shortest duration is best. Many infections like pneumonia or a bladder infection are now recommended to be treated for a much shorter duration than in the past. Longer is not generally better.
Follow up with the prescriber is essential as response to treatment is very dependent on one's past medical history and underlying condition. If a culture is done, ask for the results. If taking an antibiotic, it is very reasonable to take an over-the-counter probiotic such as Lactobacillus in order to maintain a healthy microbiome and to reduce the risk of diarrhea or yeast infection.
What can people do to reduce their need or use of antibiotics?
The benefit of routine immunization for children cannot be understated: Tdap, MMR, Hemophilus, Meningococcal, and influenza vaccines and for adults: Pneumococcal and influenza vaccines. Viral diseases such as measles or influenza can be complicated by very severe secondary bacterial infections. Pneumococcal disease continues to have a high mortality rate in adults and the vaccine does reduce mortality.
Stop smoking. It has long been known that smokers have higher post-operative infection rates. Smoking increases the risk of severe lung disease and vascular disease both of which impair natural defenses against infection.
Diabetics should monitor their blood sugar and lose weight. Careful attention to small wounds and foot care can prevent serious and limb-threatening infections.
Do not swim or wade in the bay with even a mild cut or abrasion which can provide an entry route for virulent water-borne organisms.
For those anticipating surgery, the use of Chlorhexidine soap in the shower prior to surgery is an effective way to "decolonize" yourself and reduce the risk of a post-operative wound infection.
Wash your hands. There is no evidence to support the use of special "antimicrobial" additives. Simple soap and water or an alcohol-based hand sanitizer is enough. Though the classic study by Ignaz Philipp Semmelweis was done in the 1840s, we are still working on implementing this simple common sense message.